Healthcare Provider Details

I. General information

NPI: 1073022307
Provider Name (Legal Business Name): BENITEZ UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13770 PLANTATION RD STE 3
FORT MYERS FL
33912-4460
US

IV. Provider business mailing address

13770 PLANTATION RD STE 3
FORT MYERS FL
33912-4460
US

V. Phone/Fax

Practice location:
  • Phone: 239-204-9855
  • Fax: 239-204-9330
Mailing address:
  • Phone: 239-204-9855
  • Fax: 239-204-9330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME73664
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberME73664
License Number StateFL

VIII. Authorized Official

Name: DR. OMAR BENITEZ
Title or Position: PHYSICIAN
Credential: MD
Phone: 239-204-9855